Tag Archives: Government

I can get really frustrated by people who enter into philosophical arguments about serious medical ethics questions online. Many of these people have a definite agenda, often controlling access to abortion, but try to couch it as some sort of intellectual exercise. Many of these commenters are men who toss around large words like “autonomy” and “qualitative determination.” This happens all over the interwebs, and I know better than to spend my time hunting down every blowhard that litters a comment section with his ideas on viability and fetal rights.

However, I clicked through a link on my Washington Post headline newsletter on Trisomy 18, since it is a topic that genuinely interests me. Presidential candidate and notorious crusader against contraception and abortion Rick Santorum has a daughter with Trisomy 18, one who is questionably lucky to have survived the few years she has, and has been hospitalized yet again. I was generally pleased with the accuracy and tone of the article. I hesitantly stumbled into the comments section, and then happened upon a perfect example of what I like to refer to as mental masturbation, from a commenter named “johnbmadwis”, which he wrote in response to a comment drawing the logical connection between the suffering and medical expense of Santorum’s daughter, and his position on the ability of other families to choose this road for themselves:

But haven’t you just made Santorum’s point and fueled the fire of the pro-life proponents? That is, the pro life advocate’s long held belief that abortion rights advocates are not really talking about rape and incest, but rather personal evaluations of the quality of life of the fetus or externalities such as heartache and expense. Regardless of the condition of the fetus, pro life advocates would say society has a moral interest, they’d say imperative, in preserving the life of such a fetus from individuals such as yourself, who may want to terminate that life due to such condition. At what point, if any, does that societal interest give way to individual autonomy? Would you truly advocate for the ability to terminate that life after birth? in the last weeks of pregnancy? 3rd trimester? viability? Whatever the point, what is the guiding principle? Individual autonomy? Quality of life? (determined, assuredly, by one other than the one whose life is at stake – so, whose individual autonomy?) at what point does one achieve individual autonomy? Does a fetus have individual autonomy At some point the life of the fetus does, presumably, outweigh the individual’s autonomy, right? When? Is individual autonomy equally valid if it were exercised for clearly base purposes such as mere inconvenience or desire, say, to have a boy instead of a girl? Who should make that qualitative determination? Society? The individual carrying the fetus. The affected fetus? The personal choice of a couple does affect the life of another human being in your scenario, so, it is reasonable to ask you when, if ever, do you believe that personal choice must give way to other principles or interests?

My reply, which was thankfully limited by a character limit, is here (I added a few hyperlinks to this version, but otherwise it is unchanged):

@johnbmadwis, these questions have been answered by courts and medical ethicists. There is an obvious glaring difference in autonomy between a child who is already born and a fetus, whose existence depends entirely on the mother, whose life is intimately affected and at risk by carrying a pregnancy. Late term abortions (post viability) are extremely rare, and most states have strict limits on the conditions under which such procedures can be performed.

If you are worried about a slippery slope, it is pretty obvious the slope has been tilting towards restrictive legislation limiting all abortion, not just the dramatic but rare cases you bring up. More than 400 bills have been proposed recently in state legislatures seeking to place barriers on access to abortion, from extended waiting periods for all terminations, overreaching excessive requirements for providers and facilities that don’t extend to other, riskier outpatient surgeries, to personhood bills for fertilized eggs.

Trisomy 18 is a serious condition that is considered mostly “incompatible with life.” Not only is the fetus likely to die in utero, but if it survives, it is likely to die as newborn. The article (mostly) covered this really well. (We do know the “cause” of most trisomy 18 – nondisjunction during meiosis II – which is much more common the longer the egg has been in a suspended state of meisosis, i.e. in older mothers).

Santorum’s daughter is lucky in some ways to be a 1% in more ways than one, but this is more than just some sort of ethical masturbation in a comment section of a blog. This issue involves the emotional and physical challenges to the mother. Have you ever carried a fetus, commenter with a male sounding handle? Have you ever had a stranger put their hand on your belly and ask when you were due, when you knew the fetus would most likely die before birth, or soon after? Then there’s the suffering of the baby if it survives, and the emotional toll such care takes on caregivers – do you have any idea what it is like to work in a NICU on suffering, terminal infants? With major cutbacks in personnel in public hospitals, too.

Not to mention the health care dollars arguably misproportioned here. I got to tell pregnant mothers with no insurance yesterday that they had to pay full price, cash up front for necessary basic lab tests. These are mothers who don’t have husbands flying around the country campaigning for president. These are mothers who may and do skip important labs, or prenatal visits, because they have to choose between knowing if they have hepatitis B or food for their existing children. We got to tell a mother who was having her fourth baby and desired a tubal ligation that there was no funding anymore for it. She could pay $1400 up front to the clinic then pay more in hospital fees. Maybe she could google birth control – oh, wait, she probably doesn’t have a computer.

Enjoy wringing your hands about the autonomy of a trisomy 18 fetus. It’s a luxury.

A Facebook friend posted a link to a news story about how insurance companies still say they will fight to deny coverage of preexisting conditions. I replied that I am sickened (no pun intended) by the people throwing bricks through congressional office windows, spitting on politicians, firing bullets into a congressional office, cutting a gas line at a politician’s family member’s house and calling in death threats, all in the name of defending this horrid status quo.

She asked me in reply “What do you think of all this health care stuff?”

I don’t know how much I have written about it recently, even though I have been following the debate avidly. I got turned off one step at a time with each compromise that was made, when each compromise didn’t earn one single Republican vote. What could have been a progressive reform pretty much got turned into a pretty close copy of the Republican’s answer to the Clinton era Democratic reform proposal. In fact, it uses a lot of ideas from the Republican platform in the 2008 election. We scuttled the public option, contraception coverage, put in extra barriers to abortion, cut the minimum of premiums taken in that had to go to actual medical care, removed end of life counseling, put in mandates, etc. etc. Although I think we have a gutted shell of a reform plan, it is still better than the status quo.

Here is my reply:

I am a big fan of the book “The Healing of America” by T.R. Reid. He looks at health care delivery and payment in several “civilized” countries, including countries like Switzerland that made their transition when we failed during the Clinton era.

It is grossly apparent to anyone who looks, apolitically, at health outcomes, disparities and access that the United States has one of if not the worst health care systems in the industrialized world.

I think we could easily switch over to a single payment system by simply expanding Medicare to pay for all, and then use the best elements from all of the health care systems that already work much better than ours. It’s not like there isn’t ample good examples around. Japan’s cost control and ample access to excellent practitioners and treatments (more visits to physicians per year than the US and best in all outcomes, with a fraction of our cost, and universal coverage), Canada’s self referral system, France’s electronic records card and billing (which would save billions in overhead in offices and hospitals) – for the doctors and business owners, not just the government and patients!), England’s subsidized medical education (in fact, most countries have this), and even Germany’s use of existing private insurance companies to organize the care.

What I don’t like is the knee jerk, angry reaction we have to this kind of reform in our country. In Canada, in Japan, in the UK, this isn’t a left/ right issue. It’s a matter of human rights, and it’s hard to find a politician of any stripe who wants to switch to the US system. In fact, it’s a common insult in the UK in parliament to say that another politician would rather have the US health care chaos, and it’s used by both sides.

As a future practitioner, I would hate to have to turn down a pregnant patient like I was turned down as having a “pre-existing condition” when I was pregnant. Fundamentally, I can’t see why anyone in the health care industry would support the status quo.

KevinMD invited Dr. Amy to write a post about offering VBAC, simply entitled “VBAC should not be a woman’s right”. Keep in mind on both my blog and on Academic Ob/Gyn, she has agreed the evidence supports offering VBAC. But, on this post, she mocks people who support offering VBAC, using no evidence or data, but links to blog posts and, of all things, an ad on the site of a medical malpractice firm.

The reply:

Why don’t you link to scientific evidence instead of blogs and websites of malpractice lawyers? Using inflammatory words like “bizarre” and pretending women don’t have the right to be active decision makers in their medical care is doing nothing to improve communication between physicians and their patients.

Here is the evidence report of the NIH conference on VBACs. VBAC activists are not a small group of blog writers. This is a mainstream medical cause.

Also, the pattern of obstetricians not offering VBAC has a lot more to do with the wording of a specific ACOG position statement and less to do with real medicolegal pressures. I am in Miami, which has one of if not the highest cesarean rates in the country, one of the lowest if not the lowest VBAC rates in the country, some of the worst malpractice rates and payouts in obstetrics, some of the highest malpractice insurance premiums, and really revolutionary tort reform, in that obstetricians can and mostly do “go bare”, which means that they don’t carry malpractice insurance, and effectively limit awards $250,000.

So, the only thing these docs have in common with obs throughout the country is the rocketing trend to refuse VBAC since the ACOG position statement change in 1999. They have their tort reform. They have their low VBAC rates. Their malpractice premiums haven’t gone down. Their malpractice awards and frequency of being sued hasn’t gone down. Our maternal mortality is horrendous. I can provide citations for any of that, by the way. ACOG does a yearly survey on malpractice, and they print numbers for Florida every year.

Here are two scholarly articles one and two that indicate that refusing VBAC isn’t the key to malpractice. It’s proper documentation (including during VBAC, yes I have read the first article, so don’t try to misrepresent what it says about VBAC) and evidence based standards of care. And, the AHRQ statement out of the NIH conference is the most recent, comprehensive evidence review on VBAC.

There is already good literature on risk and decision making during pregnancy if you want to talk about the rights of the pregnant patient. It reads: “These tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants.” The section on VBAC is enlightening, and calls your type of scare tactics unethical. Do you have a similarly well documented discussion published in an equally reputable journal written by practicing obstetricians that takes your point of view, that women don’t have the right to refuse elective repeat cesarean, when the most recent evidence review calls it perfectly reasonable?

I think we all know you don’t, because I have been linking to the Lyerly et al article for about a year now, and you have yet to come up with anything other than your own writing to support your point of view. Why don’t you use well established bioethical principles, and quote ACOG committee opinions on balancing the rights of women to refuse surgeries? Because they support the fundamental bioethical principles of non-malfeasance, beneficence, and autonomy of the patient. I don’t remember seeing CYA listed as a bioethical principle on weighing the rights of patients.

Calling people who are consistent with ACOG bioethics teams and the NIH “irrelevant”, “bizarre”, “Inane”, “egregious” and and “committed to resentment” is, well, bizarre, egregious, inane and committed to resentment. And, it completely ignores the basic fact that a repeat cesarean IS a procedure, and a trial of labor is the REFUSAL of a procedure. That basic inarguable “semantic” fact is the center of why women DO have the right to refuse an elective repeat cesarean. Using inflammatory insulting words doesn’t make your reasoning right NOR ethical, and when discussing rights, that is what is key.

The NIH report concludes “This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans.”

Why don’t you work with activists AND the medical establishment to get the ACOG position statement on this, and the presentation of risks, both TO obstetricians about malpractice and TO patients about all risks in pregnancy and delivery in line with evidence and bioethics?

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Commenting policy: I am committed to keeping my comment sections civil. If I criticize Dr. Amy for using verbally abusive, inflammatory tactics, I cannot ethically abide by people using the same in my comments. I am also not interested in people insulting people living with mental health diagnoses by using “crazy” or “forgot to take her meds” as insults for anyone, including me and Dr. Amy.

Amnesty International just released a report on maternal mortality (and near misses) in the United States, treating it like a human rights issue. It’s often asserted, including in this report, that infant and maternity mortality are key indicators in the health and social justice of a country.

I need to finish reading the 154 page report (ulp!) so I can get my thoughts together to be a coordinator for local lobbying. I like their proposal to ask Representatives and Senators to call on President Obama and Health and Human Services Secretary Kathleen Sebelius to create an Office of Maternal Health at DHHS, and to improve collection of data on perinatal mortality and morbidity on a state by state level.

Then, I’ll report back, and hopefully get to my cousin Susan’s birth story and the NIH VBAC conference.

Health care reform can still pass, and the Democratic image can be regained after this Massachusetts election fiasco.

I would consider scrapping what you have, and throw a curve ball to take over the news cycle from the Republicans.

Pass a simple bill (through reconciliation) that expands Medicare to people 50 and over and 20 and under. Write simple rules for the insurance companies that cover what’s left: 1. no denial of preexisting conditions. 2. At least 90% of premiums have to go to health care. 3. No denial of pregnancy or birth control coverage, or unfair treatment of women.

What do I think of the chances of the health care (method of payment and abortion) reform bill passing in the Senate? Well, considering the Senate is less liberal than the House, we have “friends” like Joe Lieberman and Ben Nelson, and a pro-life Catholic majority leader in Harry Reid, I am not optimistic.

I commented on Maternal and Infant Care Practices: Prenatal, Hospital, and Post-Delivery Care, and Paid Maternity Leave so far, but could easily comment on all of the topics. I hope they get lots of good feedback. Please comment!